After careful consideration, Salem Health has not volunteered to become an Ebola Care Center in Oregon for a number of reasons, including our core commitment to provide quality care to the communities we serve. Read Norm Gruber's letter here.

The primary goal of the Quality Operations Committee (QOC) is to improve patient care through clinical improvement projects which are physician-led, patient-centered and data-driven. The committee has responsibility for prioritization and oversight of the quality, safety, cost and patient experience improvement projects at Salem Hospital, working together with the Executive Leadership Council (ELC) and Board of Trustees. Physician partnerships in strategic planning and leadership in quality improvement projects are critical contributions as we strive to improve health care for our patients. With this in mind, the QOC was launched in December 2012, as a standing committee of the Board of Trustees. Over the last two years, it has provided a unified approach to help physicians understand the key metrics that drive operational decisions, and has facilitated physician-led improvement work.

Salem Hospital and the medical staff leadership seek to ensure that problems involving patient care and safety are consistently reported, managed and resolved. Therefore, an effort is underway to standardize the following guidelines:

PSA's reporting concerns about medical staff clinical care or professional conduct are forwarded to the Multidisciplinary Peer Review Committee. These occurrence reports are addressed through a standard process including the relevant section chief and the MPRC. See the PSA Referral Process flow diagram for more details.

Don't delay! The NFHL comes to a close on Friday, Nov. 14, and there is no time like the present to get your flu shot.

As of Thursday, Oct. 23, "The Healers" (medical staff and medical staff office) were at a 55 percent participation rate, a 13 percent jump from Week 3 but still at the bottom of the NFHL standings. Total Salem Health NFHL participation is at a whopping 73 percent! Check out Week 3 (Oct. 17) video standings here.

Egg-free, latex-free and flu mist vaccines are available at Employee Health on a first come, first served basis. You can get your shots at Employee Health, daily, from 7:30 a.m. to 4 p.m. on the second floor of Bldg. B, room 2414, or from a flu champion at the hospital. If you have received your vaccination elsewhere, please turn in or email your documentation to the medical staff office or Employee Health by Nov. 14.

Increasing Salem Health's hand hygiene compliance rate has been established as a major goal under the Quality and Safety A3 for 2015. (Our four goals under Strategy Deployment are commonly referred to as A3s, named after the large paper size they're printed on.)
"We've had hand hygiene campaigns before and they've been successful," said Jaime Nichols, director of continuous improvement. "This new initiative is different because it creates a unified, consistent push throughout our organization as a critical priority with ambitious goals in our strategic plan."

New auditing (observation) methods are being created this year through Hand Hygiene Champions to measure progress at the unit level. You can learn more about how compliance will be measured from your champion or department leader.

Awareness is being promoted throughout the hospital with a newly developed flier. The flier emphasizes how hospital acquired infections can be prevented in five critical moments:

Members of the Medical Staff Engagement Committee, the Quality Operations Committee and Executive Leadership Council evaluated three nationally recognized survey vendors and Integrated Healthcare Strategies (IHS) has been selected as the new vendor for the annual medical staff engagement survey. IHS is an industry leader with 40 years' experience monitoring the opinions, attitudes and behaviors of our nation's physicians. IHS was chosen for their expertise in the measurement of engagement, survey design and methodology, advanced statistical analysis, predictive analytics, and post-survey action planning. Survey results will be nationally benchmarked against more than 200 health care organizations. The action plans created from the survey results will drive the Physician Engagement A3 strategy for 2015-2016.

The Statesman Journal recently published a story about new Ebola training at Salem Health. The story covers the work Salem Health has been doing to get key staff trained since the new CDC guidelines for personal protective equipment were published on Oct. 20. Training includes putting on and taking off protective equipment with a buddy to ensure it is done correctly and without any issues that might put the person at risk.

Salem Hospital Ebola drill with updated CDC guidelines.

The hospital is conducting the training sessions in phases for key staffers. Phase one prioritized the emergency room and ancillary services - including 49 staff nurses, 12 emergency physicians, nine environmental services staffers, five imaging employees, five patient transporters, three respiratory therapists and one member of the hospital's rapid response team, which covers the emergency room and the rest of the campus, as a backup. Additional training will continue.

On Thursday, Oct. 23, a small group conducted a drill in the Salem Hospital ED to help determine the preparedness of staff. Watch a video of the drill here.

Thank you to everyone who has been involved in Salem Health's Ebola preparedness work, in training staff and participating in the training.

A recent story in the Statesman Journal states why Salem Health chose not to volunteer to become an Oregon Ebola Care Center. Norm Gruber is quoted in the article as saying,"Salem Health did not volunteer to become an Ebola Care Center in Oregon after determining that it would be detrimental to our ability to provide care to the communities we serve." Read the full Statesman Journal story.

For individuals concerned about unusual forgetfulness, or who are having more trouble than normal concentrating, remembering names or previous conversations. Memory screenings will be conducted by a trained screener and will take approximately 15 minutes.

For anyone who has completed the Freedom From Smoking course, this support group is led by a skilled facilitator and helps individuals learn from each other and discuss strategies to sustain the quit or to prepare for another attempt.

Starts Nov. 12, Nov. 19, Dec. 10 and Dec. 17; then every second & fourth Wednesday of each month

The new Willamette Health Partners Neurology clinic will be located in the Willamette Health Partners - Salem office at 966 12th St. SE, Suite 130. Doctors Sherif Al-Hawarey and Daniel Chen will be practicing at the new clinic and are now accepting
referrals.

In preparation for the Nov. 4 go-live of the new clinic, the referral order "CON1030 Referral to Neurology" is now available. Scheduling for appointments began on Oct. 28. If you experience any issues with the order in Epic, please call the Solution Center at 503-561-4357.

To achieve Magnet® designation takes a village or our entire hospital working together. To achieve redesignation is an even higher bar because not only is outperforming previous benchmarks expected but so is maintaining them.

Nurses share Magnet moments at Salem Hospital

"It takes a special group of people to keep Magnet top-of-mind and they are none other than the more than 80 Magnet champions at Salem Hospital," says Rick Kendall, Kaizen cinical nurse consultant and Magnet specialty practice team coordinator. "They are the wind beneath our sails that touch every facet of what it takes to achieve Magnet status. If you have a question about Magnet, please don't hesitate to ask any one of these individuals."

Multidisciplinary Peer Review Committee: Reminders when working with new nurses

A large number of new nurses have recently joined our health care team at Salem Hospital making this a good time to review some important details. First, here are just a few statistics to give you some perspective on the new hirings:

In 2013, more than 200 new graduate nurses were hired. This was due to increased volumes as well as the fact that when our patient volumes dropped in the winter of 2011, we reduced hiring accordingly.

Nearly 200 more nurses will have been hired during 2014. The next group starts this month.

Typically, hirings take place twice per year, in February and August (to coincide with college graduations). Most years about 100 nurses are hired but the past two years have been exceptions. Due to increased volume and staff shortages, new graduate programs have been added in April and November, as needed.

In light of this significant and welcome influx of new nurses, the Multidisciplinary Peer Review Committee (MPRC) emphasizes these reminders:

The MPRC reminds all medical staff members of the importance of clear, proactive communication. New nurses may be reluctant to ask questions of physicians. It is important to promote open, direct, collaborative communication with all members of the health care team - regardless of level of experience.

It is important for physicians to enter orders directly into EPIC whenever possible. Verbal orders continue to be a source of potential error, and nurses are discouraged from accepting verbal orders if computer access is available.

Medical staff members are encouraged to take every educational opportunity to help our new nurses as they continue to develop skills for providing excellent, safe patient care.

Please be aware that nursing scope of practice is very clearly defined; medical staff members are responsible for all patient care decisions involving the practice of medicine.

The laboratory positive patient identification (PPID) system will go live on inpatient floors and prep/recovery on Monday, Nov. 10. The rollout will occur is by building over several days as follows:

Monday, Nov. 10 at 8 p.m. - Bldg. B and Bldg. E

Tuesday, Nov. 11 at 8 p.m. - Bldg. A (excl. PACU)

Wednesday, Nov. 12 at 8 p.m. - Bldg. D; PACU and periop

There will be a 24/7 staffed command center effective Monday, Nov. 10 at 8 p.m. through Friday, Nov. 14, at 10 p.m. PPID superusers, IS and laboratory staff will also be on the floors supporting the rollout. The service desk will be available to receive calls at X1-HELP (4357), press 1 for PPID.

Salem Hospital is implementing a PPID System for blood draws and eventually all specimen collection. This change brings our hospital practices in line with nationally recognized best practices that ensure patient safety. Salem Hospital's laboratory processes approximately 135,000 specimens annually and our hospital averages 350 patient safety alerts for mislabels annually.

The PPID system uses handheld scanning technology to confirm patient identity and print labels at the bedside. PPID eliminates rework and improves patient safety. Because the patient's identification bracelet will be scanned when samples are collected, the technology will raise patient satisfaction by reducing patient "sticks" through re-collections.

The hospital's goal is to eliminate labeling errors, which can result in misdiagnosis and inappropriate treatment. The new technology is consistent with the hospital's system for dispensing medication.

For more information, contact Gordon Johnson, laboratory support services manager at 503-562-1110.

At a recent pharmacy and therapeutics meeting, permission was given to restrict the use of C-1 Esterase Inhibitor (Berinert) to patients with an acute attack of laryngeal, facial or abdominal hereditary angioedema (HAE). As of Oct. 11, a question now appears in the order for Epic to reiterate this restriction. If you have any questions, please contact Matt Tanner in the pharmacy at 503-814-2048.

It has been brought to the attention of the Infusion and Wound Care management team and the Wound and Ostomy Certified Nurses (WOCNs) that any debridement utilizing scissors or scalpels is considered a surgical procedure. Therefore, the WOCNs will not be allowed to do any cutting away of dead tissue until they complete a privileging process. During this transition your help is requested as follows:

Be available as an advisor for the WOCNs in order for them to be signed off.

Complete any sharps wound debridement until the process of credentialing the WOCNs can be completed.

It is hoped that the issue will be remedied as quickly as possible and your assistance in the meantime is appreciated. Thank you for your continued support of the great work the WOCNs do in providing specialized care for our patients.

For more information, contact Deanna Stein, MSN, RN, manager of infusion and wound care at 503-561-5567.

The phase 2 remodel work in the 5NW and 6NW units of Building B is almost complete. The patient move date is scheduled for Tuesday, Nov. 11, when the general surgery unit will move from 6NE to 6NW and the oncology medical/surgery unit will move from 5NE to 5NW.

Once patients are moved, the 5NE and 6NE units will have a staggered closure for about three weeks, when minor re-fix work will be done from the phase 1 remodel that ended in April of this year. This staggered approach will maximize the number of patient beds available and minimize the impact to patients as we work to provide a better environment for our patients, staff and physicians.